Smartphones become personal health coaches

In absence of national smoking "quit-line" omnipresent cellphones, websites become cheap, easy ways to help smokers kick habit.

smoking (illustrative).
(photo credit:Thinkstock/Imagebank)

Most Israelis love their smartphones and feel lost without them, while their
Internet use is among the heaviest in the world. So it would seem very logical
that these technologies, which can also have a downside, would be used for good
– to motivate the million residents over 21 (and tens of thousands of younger
ones) to kick the tobacco habit.

What’s the connection? The deadly
nicotine in tobacco is so addictive and habit forming that smokers quickly
become both physically and psychologically hooked, making it very difficult to
quit. As the Health Ministry has declined to provide a phone “quit-line” – making
Israel the only developed nation to lack such a state service – automated
services have been developed through smartphone “apps” and websites for those
who want to give up smoking or have recently done so. They are hugely popular in
the US and some other parts of the world.

Now a US expert on using
digital technology to promote smoking cessation is here on a three-month
sabbatical at the Hadassah-Hebrew University Braun School for Public Health and
Community Medicine in Jerusalem, working on creating such a model for Israeli
smokers.

Prof. Lorien Abroms has developed during her stay an Israeli
version of the text-messaging program called Text2Quit for local smokers. An
associate professor of prevention and community health at George Washington
University’s School of Public Health and Health Service in Washington, DC,
Abroms was the guest speaker at a recent symposium at Hadassah University
Medical Center in Ein Kerem.

The title was “Smoking Cessation Through the
Use of Modern Media” and the symposium was attended by about 100 people in the
public health field.

“As a tourist, I have noticed that Israelis eat
well, are very good in English and love their technology – especially their
cellphones. So there are good opportunities here for reducing smoking rates and
second-hand smoke exposure. Health-related services delivered by mobile
communications devices – known as mHealth – can advance research, prevent
disease, enhance diagnostics, improve treatment, reduce disparities, increase
access to health services and lower healthcare costs in ways previous
unimaginable,” she continued.

“The UN has even created the m-Health
Alliance especially to promote the technology in developing
countries.

One can go to a remote African village where there is no
running water. But it is likely that even some people have cellphones
there.”

Of the 91 percent of Israelis who have at least one cellphone,
68% of the devices are the more expensive smartphones.

“They’ve
infiltrated our lives. A survey has shown that 82% of Americans never leave home
without their cellphones, 68% sleep with the phone at their bedside. We’re
almost married to them,” declared the US expert. “The reach of mHealth programs
are scalable; one can start small on a local basis and then expand to be a
national service. The price is low, cheaper than other public health
alternatives and even cheaper than smoking quit-lines that are manned by humans
around the clock.”

Smokers can easily enroll in such services. The Amazon
bookselling site has patented one-click shopping, storing all the purchase
details and requiring customers to click a computer mouse only once to order a
book. One can now do the same thing on a smartphone to enroll in a
smoking-cessation program.

Even before there were smartphones, New
Zealand health authorities began to offer in 2008 the ability to send and
receive text messages; Australia followed, and the US now has two such free
services, Text2Quit and SmokefreeTXT.

Smokers can contact them anytime to
receive interactive messages if they feel the urge to light up but want to fight
the nicotine cravings.

“I work with pregnant smokers. They suffer a lot
of stigma, as they don’t like to admit they smoke and can harm their fetuses.
With smartphone messages, the service can be unobtrusive and confidential.
Nobody will single them out. And as smokers often light up when they’re on their
cellphone, learning to change health behaviors from the phone is
perfect.”

It’s like having a health coach in your pocket. Instead of
going to a doctor for an appointment to discuss quitting smoking, one can learn
how to do it, set goals and get feedback on one’s performance around the
clock.

Among the text messages are encouragement such as “By not smoking
since Thursday, you have saved NIS 80,” or you will live at least two days
longer by not lighting up.”

Smokers who quit but were overwhelmed and had
the urge to buy cigarettes can even get a human “buddy” who would talk them out
of it any time of the day or night. The technology can work well for other
health behaviors including weight loss and diabetes management.

A study
using ordinary text messaging to quit smoking that was published in The Lancet
included 5,800 people and a control group. They received five messages a day for
five weeks, then three daily for 26 weeks. Saliva samples were tested for
cotinine, a substance that shows a person smoked recently.

Thanks to the
text messaging, 10.7% stopped smoking, compared to only 4.9% in the control
group that lacked this service. While this is not extremely high, conceded
Abroms, it was higher than other interventions. It reaches a lot of people, so
it can have an important impact. There were published studies since then, giving
enough evidence to recommend mobile phone-based interventions.

Studies
showing the effect of smartphone apps for smoking cessation have not yet been
published, but she is certain that they will be shown just as effective or even
more so.

“In 2009, there were 47 such apps available through the iPhone,”
Abroms reported. “Today, there are over 200 for iPhone and a similar number for
Android phones.” Some of them offer “hypnosis by smartphone,” but the George
Washington University professor said she doubted that this would be
effective.

“Apps could take better advantage of social
networking.

But we have shown that text messaging on any cellular phone
works well to promote smoking cessation.

Most participants say they give
them confidence.

They liked the regularity of texts and information sent
to them and to pass the quit date they had committed themselves to observe. It’s
as if somebody is with you.

It gives good ideas on fighting
cravings.”

The Israeli version of Text2Quit that Abroms has developed
here, called the iStopSmoke program, was produced in English rather than Hebrew
to save money while checking feasibility and user preference.

Thus
English-speaking Israeli smokers over 18 were recruited for a pilot study to see
how the US version had to be adapted for locals.

“There is no human
support now, as it is all computer generated, with text messages and alerts to
guide behavior change. But if a smoker tells the smartphone that they lapsed,
they could be connected to a human they could speak to,” she
concluded.

“As Israel is way ahead of the US in universal digital medical
records in the health funds, these services could be very effective. The future
for the use of such smoking cessation technology is very bright. The country can
be a real world leader in smoking cessation.

Doctors will be able to see
on your electronic medical file if you are a smoker and want to quit. Then you
would need only one click to join. We hope to have quitline information on
cigarette packs. The same thing can be done on Text2Quit.”

It was at the
symposium that Hadassah Medical Organization director-general Prof. Ehud Kokia
and Hebrew University Medical Faculty dean Prof. Eran Leitersdorf announced that
the Ein Kerem campus will voluntarily be totally smoke free in three years, the
first public notobacco zone in the country.

“It’s not simple,” said
Kokia, “but we are working on it. The electronic media are different, and we
have to learn how to use them for this purpose.”

Leitersdorf added that a
few months ago, the university and Hadassah announced that the outdoor
Ben-Gurion Square was officially smoke free, even though the law then did not
bar it.

“We installed signs, and I often look out the window to check if
it was being observed. I saw a pharmacy student smoking near the signs. I
pointed to to them, and she said: ‘Very interesting!’ When I ask smokers if they
saw the warnings, they say: ‘I got used to it’ or ‘It’s good that it says so!’
So there is a way to go. Staffers who smoke will in three years no longer be
able to leave the buildings on campus and take a smoke. They will have to wait
until they leave the area.”

But making Hadassah’s Mount Scopus hospital
campus smoke free will certainly take longer, as half of all patients are Arabs
due to the east Jerusalem location, and 44% of Arab men are addicted to
tobacco.

Health Ministry public health chief Prof. Itamar Grotto
confessed, to the shock of the audience, that he was a smoker himself – until he
was asked during an interviewed by Army Radio journalist Razi Barkai whether he
smoked. He was head of the IDF medical branch at the time.

“I said I
didn’t, too embarrassed to admit that I did.

The soldiers I worked with
were shocked when I threw my pack of cigarettes into the garbage can, and I
never smoked since,” he recalled. “It was real shock therapy.”

Dr. Shani
Afek, chairman of the Medical Society for Smoking Prevention and Cessation,
noted that from his experience, changing health behavior is very
complicated.

Smoking cessation through technology is still young, he
said.

“Our society will continue to promote quitting smoking in every
way. Our skills have to grow with experience and technology.”

School of
Public Health dean Prof. Orly Manor said that the future smoking ban on campus
is a stage in her school’s program to promote public health among students and
staff. She too admitted that she started smoking as a postdoctoral student in
England in her 30s but quit.

Dr. Haggai Levine, a researcher at Manor’s
school with a special emphasis on smoking cessation, conducted a live poll of
the audience using special broadcast devices and found that 85% of those present
thought medical professionals must give the public a personal example and not be
smokers.

With the Health Ministry abandoning its responsibility for a
quit-line, only Maccabi Health Services has offered such a telephone service for
its own members since 2009.

“It’s not in the basket of health services,”
said Haim Filosof, director of Maccabi’s quit-line. “It is free for members but
at our expense. We would be happy if it became a national service provided by
the government.

When we thought of launching ours, we worried at first,
as a lot of eyebrows were raised about using it, but it works very successfully.
The best part is that it’s anonymous; the person who answers the call doesn’t
see the smoker or know his name. It is not threatening.

“Our aim is to
raise the number of Maccabi members who are smokers and want to quit by 30% to
1,000 members a year. We took on Pfizer, which makes Champix, the drug to help
people quit, as a strategic partner. Sixty percent of smokers we contacted said
they would join a quit-line if we had one.”

The health fund doctor is
updated on the results of the counseling by phone. The Maccabi cessation
adviser calls the patient every week. Members who enroll receive a coupon for a
two-week supply of nicotine patches, but few have used them. The conversations
average 20 minutes each. Maccabi, who which has so far handled only 2,800 people
under the program, with 200 new requests every month, realizes that it’s only a
drop in the bucket. But every member who quits smoking means a healthier person
and fewer medical expenses.

Of those who finish the quit-line course,
about two-thirds actually quit, and of these, about 45% are still tobacco free a
year later. Maccabi hopes to add a website for smoking cessation as well.